TN 35 (11-21)
NL 00725.007 NOA Letter with Payment Summary
Social Security
Administration
Retirement,
Survivors, and Disability Insurance
Notice of Award
Miscellaneous Program Service Center
225 E. Oak Street
Central City, ST 00000
Date:
BNC:
21MS123J45678-A
JOHN G. BENEFICIARY
101 MAIN STREET
ANYTOWN, ST 00001
You are entitled to monthly retirement benefits beginning November 1989.
What We Will Pay And When
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•
You will receive $828.20 around February 10, 1989. This is the money you are due for
November 1989 through January 1990.
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You will receive $286 for February 1990 around March 3, 1990.
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After that you will receive $286 each month.
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Later on in this letter, we will show you how we figured these amounts.
Your Benefits
We raised your monthly benefit amount beginning December 1989 because the cost of
living increased.
Work and Earnings Affect Payments
The monthly earnings test applies only to 1 year. That year is the first year a beneficiary
has a non-work month after entitlement to Social Security benefits. Our records show
that you had or will have at least one non-work month in 1990. If you ever go to work,
we will pay benefits for each year based on your work and earnings for that year.
Information About Medicare
You are entitled to Medicare hospital and medical insurance beginning November 1988.
We will send your Medicare card in about 4 weeks. You should take this card with you
when you need medical care. If you need care before you receive the card, use this
letter as proof that you are covered by Medicare.
The pamphlet we have enclosed, “Basic Facts About Medicare and Other Health Insurance,”
gives you more information about the Medicare program.
Other Social Security Benefits
The benefits described in this letter is the only one you can receive from Social
Security. If you think you might qualify for another kind of Social Security benefit
in the future, you will have to file another application.
Do You Think We Are Wrong?
If you think we are wrong, you have the right to appeal. We will correct any mistakes
and will look at any new facts you have. A person who did not make the first decision
will decide your case.
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You have 60 days to ask for an appeal.
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The 60 days start the day after you get this letter.
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You must have a good reason if you wait more than 60 days to ask for an appeal.
Your Responsibilities
Your benefits are based on the information you gave us. If this information changes,
it could affect your benefits. For this reason, it is important that you report changes
to us right away.
We have enclosed a pamphlet, “When You Get Social Security, Retirement or Survivors
Benefits...What You Need To Know.” It tells you what you must be reported and how
to report. Please be sure to read the part of the pamphlet which explains how work
could changes your payments.
If You Have Any Questions
If you have any questions, you may call us at 1-800-2345-SSA. We can answer most questions
over the phone. You can also write any Social Security office. The office that serves
your area is located at:
Street address
City, State Zip
If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment at the office. This will help us serve you more quickly when
you arrive at the office.
Social
Security Administration
Enclosure(s):
Pub 05-10077
PAYMENT SUMMARY
Your Payment of $828.20
Here is how we figured your first payment:
Benefits due for November 1989 through
January 1990 including the cost of living
increase, less monthly rounding of benefits . . . . . . . . . . . .
. . . . . . . . . . $ 941.60
Amount we subtracted because of:
o premiums for medical insurance
through January 1990 . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 81.50
o Additional premium due
one month in advance . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 31.90
This equals the amount of the first payment . . . . . . . . . . . . . . . . . . .
. . . . . . . . $ 828.20
Your Regular Monthly Payment
Here is how we figured your regular monthly payment beginning February 1990:
You are entitled to a monthly benefit of . . . . . . . . . . . . . . . . . . .
. . . . . . . . . $ 318.70
Amounts we subtracted because of:
o premium for medical insurance . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 31.90
This equals . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 286.80
o rounding (we must round down to a whole dollar) . . . . . . . . . . . .
. . . . . .80
This equals the amount of the regular monthly payment . . . . . . . . . . . . .
. . $ 286.00